NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Notice of Privacy Practices (the "Notice") describes the privacy practices of Blackwell Medical, LLC ("Company") as required under The Health Insurance Portability and Accountability Act ("HIPAA").
Company wants you to know that nothing is more central to our operations than maintaining the privacy of your health information ("Protected Health Information" or "PHI"). PHI is information about you, including basic information that may identify you and relates to your past, present or future health or condition. We take this responsibility very seriously.
Our Pledge Regarding Your Health Information
We are required by law to protect the privacy of your health information and to provide you with this Notice covering our legal duties and privacy practices regarding your health information. We are also required to notify you in the event there is a breach of your PHI. Our employees required to protect the confidentiality of your PHI and will disclose your PHI to a person other than you or your personal representative only when permitted under federal or state law. This protection extends to any PHI that is oral, written, or electronic, such as treatment information transmitted by facsimile, modem, or other electronic device. This Notice describes how we may use and disclose your PHI. In some circumstances, as described in this Notice, the law permits us to use and disclose your PHI without your express permission. In all other circumstances, we will obtain your written authorization before we use or disclose your PHI. This Notice also describes your rights and the obligations we have regarding the use and disclosure of your PHI. Under federal and applicable state law, we are required to follow the terms of the Notice currently in effect. In some situations, state privacy or other applicable laws may provide greater privacy protections than those stated in this Notice. For example, depending on the state in which you reside, there may be additional state law privacy protections related to communicable diseases, reproductive health, substance abuse and mental health. When appropriate, we will follow these state or other applicable laws. Please contact us at 64 Elizabeth Blackwell Street Suite D, United States, NY 14456 or (585) 394-6524 ("Contact Person") if you would like a copy of the more protective privacy laws, if any, in your state.
How We May Use and Disclose Your PHI Without Your Permission For Treatment, Payment or Health Care Operations
Below are examples of how federal law permits use or disclosure of your PHI for these purposes without your permission:
1. Treatment: PHI obtained by Company will be used to provide you with treatment for your sleep disorder or for other medical purposes. We may also use and disclose your PHI to your physician or other health care provider to recommend treatment options or alternatives, or to tell them about issues related to your therapy. We may contact you to provide treatment-related services, such as treatment alternatives, compliance programs and other health care services that may be of interest to you.
2. Payment: We may contact your insurer, payor or other agent and share your PHI with that entity to determine whether it will pay for your treatment and the payment amount. We may also contact you about a payment or balance due.
3. Health care operations: Your PHI may be used to monitor the effectiveness of our services. Your PHI may be transferred for purposes of carrying out our services if we buy or sell our business. We may also use your PHI to tell you about health savings available and other opportunities that may be of interest to you, such as health education programs, health-related benefits for certain customers or clinical research projects. We may also disclose your PHI to another health care provider or health plan for purposes of their treatment, payment or health care operations. However, we will only do so for their health care operations if they have or have had a relationship with you, if the PHI they request pertains to that relationship, and only for limited purposes, such as conducting quality improvement activities, reviewing the performance of a health care provider, or training purposes.
OTHER SPECIAL CIRCUMSTANCES: In addition to the above, we are permitted under federal and applicable state law to use or disclose your PHI without your permission only in certain circumstances, as described below.
1. Business associates: We provide some services through other entities termed "business associates." Federal law requires us to enter into contracts with these entities to require them to safeguard your PHI and use and disclose it only as specified by Company. Individuals involved in your care or payment for care: We may disclose your PHI to a friend, personal representative or family member involved in your medical care or payment for your care. For example, if we can reasonably infer that you agree, we may provide medical information to your caregiver on your behalf. Disclosures to parents or legal guardians: If you are a minor, we may release your PHI to your parents or legal guardians when we are permitted or required under federal and applicable state law.
2. Workers’ compensation: We may disclose your PHI to the extent authorized and necessary to comply with laws relating to workers’ compensation or similar programs established by law.
3. Law enforcement: We may disclose your PHI for law enforcement purposes as required by law or in response to a court order and in certain conditions, a subpoena, warrant, summons or similar process; to identify or locate a suspect, fugitive, material witness or missing person; about a death resulting from criminal conduct; about crimes on the premises or against a member of our workforce; and in emergency circumstances, to report a crime, the location, victims, or the identity, description, or location of the perpetrator of a crime.
4. As required by law: We must disclose your PHI when required to do so by applicable federal or state law.
5. Judicial and administrative proceedings: We may disclose your PHI in response to a court or administrative order, and under certain conditions, a subpoena, discovery request or other lawful process.
6. Public health: We may disclose your PHI to federal, state or local authorities, or other entities charged with preventing or controlling disease, injury or disability for public health activities.
7. Health oversight activities: We may disclose your PHI to an oversight agency for health oversight activities authorized by law. These activities include audits, investigations, inspections, licensing and for government monitoring of the health care system, government programs, and compliance with federal and applicable state law.
8. United States Department of Health and Human Services: Under federal law, we are required to disclose your PHI to the U.S. Department of Health and Human Services to determine if we are in compliance with federal laws and regulations regarding the privacy of health information.
9. Research: Under certain circumstances, we may use or disclose your PHI for research purposes. However, we will only do so if the research project has been approved by an institutional review board or privacy board that has established protocols to ensure the privacy of your PHI.
10. Coroners, medical examiners and funeral directors: We may release your PHI to assist in identifying a deceased person or determine a cause of death.
11. Administrator or executor: Upon your death, we may disclose your PHI to an administrator, executor or other similarly authorized individual under applicable state law.
12. Organ or tissue procurement organizations: Consistent with applicable law, we may disclose your PHI to organ procurement organizations or other entities engaged in the procurement, banking or transplantation of organs for the purpose of tissue donation and transplant.
13. Notification: We may use or disclose your PHI to assist in a disaster relief effort so that your family, personal representative or friends may be notified about your condition, status and location.
14. Correctional institution: If you are or become an inmate of a correctional institution, we may disclose to the institution or its agents PHI necessary for your health and the health and safety of others.
15. To avert a serious threat to health or safety: We may use and disclose your PHI to appropriate authorities when necessary to prevent a serious threat to your health and safety or the health and safety of another person or the public.
16. Military and veterans: If you are a member of the armed forces, we may release your PHI as required by military command authorities. We may also release PHI about foreign military personnel to the appropriate military authority.
17. National security and intelligence activities: We may release your PHI to authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law.
18. Protective services for the President and others: We may disclose your PHI to authorized federal officials so that they may provide protection to the President, other authorized persons, or foreign heads of state, or conduct special investigations.
How We May Use or Disclose Your PHI for Other Purposes Only With Your Authorization.
Your written authorization to use and disclose your PHI is required in order for us to:
- Use and disclose psychotherapy notes containing your PHI (to the extent we hold any)
- Send marketing communications to you. If we will receive payment for making a marketing communication, we will state this in the authorization.
- Receive payment in exchange for your PHI.
In addition to the above situations, any other uses and disclosures of your PHI not described elsewhere in this Notice will be made only with your prior written authorization. You may revoke this authorization at any time by submitting a written notice to our address listed below. Your revocation will not apply to information released before we receive it.
You have the following rights with respect to your PHI:
- Obtain a paper copy of the Notice upon request. To obtain a copy at any time, please send a request to Contact Person.
- Inspect and obtain a copy of your PHI. You have the right to access and copy your PHI contained in a "designated record set," which may include medical information and billing records. You may request an electronic copy of your PHI records that we maintain electronically. To inspect or obtain a copy of your PHI, submit a written request to Contact Person. You may also ask us to provide a copy of your PHI to another person. In that case, your written request must be signed by you, must clearly identify the person to whom you want us to send the copy of your PHI, and must state where the copy is to be sent. We will respond to your request in writing within 30 days. A fee may be charged for the expense of fulfilling your request. We may deny your request in certain limited circumstances, such as if we have reasonably determined that providing access to PHI would endanger your life or safety or cause substantial harm to you or another person. If we deny your request, we will notify you in writing and provide you with the opportunity to request a review of the denial.
- Request an amendment of PHI. If you feel that your PHI maintained by us in a "designated record set" is incomplete or incorrect, you may request that we amend it. To request an amendment, submit a written request to Contact Person. Requests must identify: (i) which information you seek to amend, (ii) what corrections you would like to make, and (iii) why the information needs to be amended. We will respond to your request in writing within 60 days (with a possible 30-day extension). In our response, we will either: (i) agree to make the amendment, or (ii) inform you of our denial, explain our reason and outline appeal procedures. If denied, you have the right to file a statement of disagreement with the decision. We will provide a rebuttal to your statement and maintain appropriate records of your disagreement and our rebuttal.
- Receive an accounting of disclosures of PHI. You have the right to request an accounting of disclosures of your PHI for purposes other than treatment, payment or health care operations. This accounting will also exclude disclosures: made directly to you, made with your authorization, made to your caregivers, and certain other disclosures. To obtain an accounting, submit a written request to the Contact Person. Requests must specify the time period, not to exceed six years. We will respond in writing within 60 days of receipt of your request (with a possible 30-day extension). We will provide one free accounting per 12-month period, but you may be charged for the cost of any subsequent accountings during the same period. We will notify you in advance of the cost involved, and you may choose to withdraw or modify your request at that time.
- Request communications of PHI by alternative means or at alternative locations. You have the right to request that we communicate with you in a certain way or at a certain location. For example, you may request that we contact you only in writing at a specific address. To request confidential communication of your PHI, submit a written request to the Contact Person. Your request must state how, where or when you would like to be contacted. We will accommodate all reasonable requests.
- Request a restriction on certain uses and disclosures of PHI. You have the right to request a restriction or limitation on our use or disclosure of your PHI. You must identify in this request: (i) what particular information you would like to limit, (ii) whether you want to limit use, disclosure, or both, and (iii) to whom you want the limits to apply. We will consider your request but are not required to agree to it unless it is a plan restriction. A plan restriction is one that meets the following three conditions: (A) it is to restrict disclosure of your PHI to a health plan for purposes of payment or health care operations; (B) the PHI relates solely to a health care item or service for which you, or someone on your behalf, has paid us in full; and (C) the disclosure is not otherwise required by law. We will not agree to a plan restriction unless we have first received payment in full for the item or service. We will also not agree to a plan restriction if by law we are required to submit your PHI to the plan. If you wish to request a plan restriction, you must make your request by calling Contact Person. When you call you will need to provide the following information: (1) your full name, date of birth, address and plan identification number; (2) the information to which you would like the restriction to apply; and (3) the name of the plan(s) with which the data may not be shared for payment and health care operation purposes. If we do agree to a restriction, we will not apply the restriction in the event of an emergency. Except for plan restrictions, we have the right to terminate the restriction if: (i) you agree orally or in writing to terminate the restriction, or (ii) if we inform you of the termination, which becomes effective only for your PHI created or received after we inform you of the termination.
For all other restriction requests, please contact Contact Person. All requests must include your full name, date of birth, address and plan identification number.
Complaints: If you believe your privacy rights have been violated, you can file a complaint with Contact Person or with the Secretary of the United States Department of Health and Human Services.